Background: The joint presentation of elevated aspiration risk and difficult airway is uncommon. Epiphrenic esophageal diverticulum (EED) is a rare disease with an estimated incidence of 1:500,000 cases annually. It is associated with an increased risk of aspiration for patients who undergo general anesthesia, which necessitates prompt securement of the airway upon induction. However, coexisting tracheal stenosis challenges the airway management for these particular patients. There are no published case reports describing these problems as independent issues in a single case. We describe the anesthetic management for a laparoscopic fundoplication in a patient with a large EED and severe tracheal stenosis.
Case Description: A 66-year-old woman with EED presented for a laparoscopic esophageal diverticulectomy, Heller myotomy, and Toupet fundoplication for dyspnea and worsening regurgitation. Previous esophagogram showed a 5.9 x 4.6 x 6.7-cm lower esophageal diverticulum (see Figure). During a workup for her dyspnea, the patient was found to have tracheal stenosis with a diameter of 4 mm at its narrowest; consequently, her trachea was dilated to 14 mm in 2014. Her anesthesia record at the time noted an uneventful course including easy mask ventilation following induction. Since the dilatation, there were no changes in symptoms or follow-up procedures to suggest relapse of tracheal stenosis. On the morning of surgery we discussed with the surgical team and assembled appropriate airway equipment and backup devices to accommodate possible conversion to thoracic approach. The patient was pre-oxygenated and placed in the Semi-Fowler’s position. Anesthesia was induced with propofol and succinylcholine following the RSI protocol. We began our intubation attempts with a 35-French (Fr) MallinckrodtTM double-lumen endotracheal tube (DLT; outside diameter [OD] 13.3 mm) and subsequently a 33-Fr DLT (OD 12.3) using a GlideScope, but unexpectedly failed. Then we switched to MallinckrodtTM single-lumen endotracheal tubes (ETT) via fiberoptic intubation. We were unable to pass a 7.0 ETT (OD 9.5) or a 6.5 ETT (OD 8.9), but managed to guide a 6.0 ETT (OD 8.2) through the most constricted portion of the patient’s trachea. Following intubation, auscultation of the lungs revealed clear breath sounds bilaterally. The fundoplication was performed successfully by abdominal approach without need for lung isolation. The ENT team was then consulted intraoperatively to perform tracheal dilation; they replaced the existing 6.0 ETT with an 8.0 ETT (OD 11.0 mm) without resistance. Upon emergence, the patient was fully awake and a negative cuff-leak test was achieved. We subsequently inserted a CookTM airway exchange catheter through the 8.0 ETT tube and extubated her while leaving the catheter in place. The patient maintained a patent airway and the catheter was removed thereafter. The patient’s postoperative course was uneventful; she was discharged home on her third postoperative day.
Discussion: We demonstrated the successful anesthetic management of a patient with a high potential for pulmonary aspiration and difficult airway. In this case it was critical to communicate well with the surgical teams, perform a careful assessment of airway and imaging studies, conduct full aspiration precautions, and avoid inadvertent insertion of equipment into an abnormal esophagus.
